Page 28 - Williams Hematology ( PDFDrive )

4 Part I: Clinical Evaluation of the Patient Chapter 1: Initial Approach to the Patient: History and Physical Examination 5

Invasion or compression of the brain by leukemia or lymphoma, or lymph nodes of lymphomas may be tender or painful because of sec-
opportunistic infection of the central nervous system by Cryptococcus ondary infection or rapid growth. Painful or tender lymphadenopathy
or Mycobacterium species, may also cause headache in patients with is usually associated with inflammatory reactions, such as infectious
hematologic malignancies. Hemorrhage into the brain or subarachnoid mononucleosis or suppurative adenitis. Diffuse swelling of the neck and
space in patients with thrombocytopenia or other bleeding disorders face may occur with obstruction of the superior vena cava due to lym-
may cause sudden, severe headache. phomatous compression.
Paresthesias may occur because of peripheral neuropathy in perni-
cious anemia or secondary to hematologic malignancy or amyloidosis. Chest and Heart
They may also result from therapy with vincristine. Both dyspnea and palpitations, usually on effort but occasionally at
Confusion may accompany malignant or infectious processes rest, may occur because of anemia or pulmonary embolism. Congestive
involving the brain, sometimes as a result of the accompanying fever. heart failure may supervene, and angina pectoris may become manifest
Confusion may also occur with severe anemia, hypercalcemia (e.g., in anemic patients. The impact of anemia on the circulatory system
myeloma), thrombotic thrombocytopenic purpura, or high-dose glu- depends in part on the rapidity with which it develops, and chronic
cocorticoid therapy. Confusion or apparent senility may be a mani- anemia may become severe without producing major symptoms; with
festation of pernicious anemia. Frank psychosis may develop in acute severe acute blood loss, the patient may develop shock with a nearly
intermittent porphyria or with high-dose glucocorticoid therapy. normal hemoglobin level, prior to compensatory hemodilution. Cough
Impairment of consciousness may be a result of increased intracra- may result from enlarged mediastinal nodes compressing the trachea
nial pressure secondary to hemorrhage or leukemia or lymphoma in or bronchi. Chest pain may arise from involvement of the ribs or ster-
the central nervous system. It may also accompany severe anemia, poly- num with lymphoma or multiple myeloma, nerve-root invasion or com-
cythemia, hyperviscosity secondary, usually, to an immunoglobulin (Ig) pression, or herpes zoster; the pain of herpes zoster usually precedes
M monoclonal protein (uncommonly IgA or IgG) in the plasma, or a the skin lesions by several days. Chest pain with inspiration suggests a
leukemic hyperleukocytosis syndrome, especially in chronic myeloge- pulmonary infarct, as does hemoptysis. Tenderness of the sternum may
nous leukemia. be quite pronounced in chronic myelogenous or acute leukemia, and
occasionally in primary myelofibrosis, or if intramedullary lymphoma
Eyes or myeloma proliferation is rapidly progressive.
Conjunctival plethora is a feature of polycythemia and pallor a result of
anemia. Occasionally blindness may result from retinal hemorrhages Gastrointestinal System
secondary to severe anemia and thrombocytopenia or blurred vision Dysphagia has already been mentioned under “Nasopharynx, Orophar-
resulting from severe hyperviscosity resulting from macroglobulinemia ynx, and Oral Cavity” above. Anorexia frequently occurs but usually has
or extreme hyperleukocytosis of leukemia. Partial or complete visual no specific diagnostic significance. Hypercalcemia and azotemia cause
loss can stem from retinal vein or artery thrombosis. Diplopia or distur- anorexia, nausea, and vomiting. A variety of ill-defined gastrointestinal
bances of ocular movement may occur with orbital tumors or paralysis complaints grouped under the heading “indigestion” may occur with
of the third, fourth, or sixth cranial nerves because of compression by hematologic diseases. Abdominal fullness, premature satiety, belching,
tumor, especially extranodal lymphoma, extramedullary myeloma, or or discomfort may occur because of a greatly enlarged spleen, but such
myeloid (granulocytic) sarcoma. splenomegaly may also be entirely asymptomatic. Abdominal pain may
arise from intestinal obstruction by lymphoma, retroperitoneal bleed-
Ears ing, lead poisoning, ileus secondary to therapy with the vinca alkaloids,
Vertigo, tinnitus, and “roaring” in the ears may occur with marked acute hemolysis, allergic purpura, the abdominal crises of sickle cell dis-
anemia, polycythemia, hyperleukocytic leukemia, or macroglobuline- ease, or acute intermittent porphyria. Diarrhea may occur in pernicious
mia-induced hyperviscosity. Ménière disease was first described in a anemia. It also may be prominent in the various forms of intestinal
patient with acute leukemia and inner ear hemorrhage.
malabsorption, although significant malabsorption may occur without
Nasopharynx, Oropharynx, and Oral Cavity diarrhea. In small-bowel malabsorption, steatorrhea may be a notable
Epistaxis may occur in patients with thrombocytopenia, acquired or feature. Malabsorption may be a manifestation of small-bowel lym-
inherited platelet function disorders, and von Willebrand disease. phoma. Gastrointestinal bleeding related to thrombocytopenia or other
Anosmia or olfactory hallucinations occur in pernicious anemia. The bleeding disorder may be occult but often is manifest as hematemesis
nasopharynx may be invaded by a granulocytic sarcoma or extranodal or melena. Hematochezia can occur if a bleeding disorder is associated
lymphoma; the symptoms are dependent on the structures invaded. The with a colonic lesion. Constipation may occur in the patient with hyper-
paranasal sinuses may be involved by opportunistic organisms, such as calcemia or in one receiving treatment with the vinca alkaloids.
fungus in patients with severe, prolonged neutropenia. Pain or tingling
in the tongue occurs in pernicious anemia and may accompany severe Genitourinary and Reproductive Systems
iron deficiency or vitamin deficiencies. Macroglossia occurs in amyloi- Impotence or bladder dysfunction may occur with spinal cord or periph-
dosis. Bleeding gums may occur with bleeding disorders. Infiltration of eral nerve damage caused by one of the hematologic malignancies or
the gingiva with leukemic cells occurs notably in acute monocytic leu- with pernicious anemia. Priapism may occur in hyperleukocytic leu-
kemia. Ulceration of the tongue or oral mucosa may be severe in the kemia, essential thrombocythemia, or sickle cell disease. Hematuria
acute leukemias or in patients with severe neutropenia. Dryness of the may be a manifestation of hemophilia A or B. Red urine may also occur
mouth may be caused by hypercalcemia, secondary, for example, to with intravascular hemolysis (hemoglobinuria), myoglobinuria, or
myeloma. Dysphagia may be seen in patients with severe mucous mem- porphyrinuria. Injection of anthracycline drugs or ingestion of drugs
brane atrophy associated with chronic iron-deficiency anemia. such as phenazopyridine (Pyridium) regularly causes the urine to turn
red. The use of deferoxamine mesylate (Desferal) may result in rust col-
Neck ored urine. Amenorrhea may also be induced by certain drugs, such as
Painless swelling in the neck is characteristic of lymphoma but may be antimetabolites or alkylating agents. Menorrhagia is a common cause
caused by a number of other diseases as well. Occasionally, the enlarged of iron deficiency, and care must be taken to obtain a history of the

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